Mental Health Coverage Expands, But Are There Enough Providers?

The Affordable Care Act isn’t just about access to primary care physicians and prescription drugs. It also requires insurers to provide benefits to people with mental illness, emotional disorders and substance abuse problems.

But some health professionals are worried there might not be enough psychiatrists and psychologists to go around.

Under the Affordable Care Act of 2010, widely known as Obamacare, all individual and small group insurance policies sold in Oklahoma and other states must provide a number of essential health benefits, starting Jan. 1.

The essential benefits include mental health and substance abuse services such as individual counseling and psychotherapy.

A separate federal law passed in 2008 requires insurers to provide “parity” between conventional medical care and mental health care. Co-pays, deductibles, and the number of doctor visits and hospital days must be comparable.

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Experts say the combined impact of the two laws could be substantial: Mental health and substance abuse benefits will be more generous than they have been in the past, and affordable coverage will be available to more people.

“The main thing ACA does is it provides coverage for people that don’t have coverage,” said Mental Health Commissioner Terri White, who manages Oklahoma’s overloaded mental health and substance abuse programs. “There are a lot of people with mental illness that we serve that don’t have any health coverage.”

According to the U.S. Census Bureau, 685,076 of Oklahoma’s 3.7 million residents did not have health insurance last year.

Of those, an estimated 145,000 poor people don’t have much to gain from Obamacare for now. That’s because Oklahoma refused to participate in a Medicaid expansion that would have provided them with low or no-cost coverage, including mental health and substance abuse services.

The law’s biggest immediate impact will be on an estimated 256,000 uninsured Oklahomans above the poverty line who will qualify for federal tax credits if they purchase insurance through the federal marketplace that began operating Oct. 1. Although the marketplace’s launch has been crippled so far by website problems, the Obama administration has promised to fix most of the bugs by Dec. 1.

The Affordable Care Act requires most Americans to buy health insurance starting in 2014. The federal tax credits will significantly reduce the cost of policies for those who qualify, in some cases to zero. The credits will be available to people with annual household incomes ranging from $11,490 to $94,200, depending on family size.

Federal officials have estimated that one in four people without insurance have mental health or substance abuse problems. Nationwide, 32 million people are expected to gain access to mental health coverage through Obamacare.

But access to coverage doesn’t necessarily guarantee access to providers.

In some states, officials have questioned whether the number of private-practice mental health professionals is sufficient to meet the potential demand generated by thousands of new patients.

White said the state mental health department does not collect data on the adequacy of the private-practice network. She said she was not sure whether it would be sufficient to handle all the people who will gain coverage next year.

According to the U.S. Health Resources and Services Administration, every county in Oklahoma except one, Grady, has one or more “health professional shortage areas” for mental health practitioners. Most counties also have shortage areas for primary care providers as well.

“There is no infrastructure for taking on this new population,” said Mary Jane Argentos, a clinical psychologist in Norman. “For people who do what I do, which is very individualized and, I hope, high-quality health care, we are already overbooked.”

Argentos said Oklahoma has too few practicing psychiatrists and psychologists. She said the problem has grown more acute because of the large number of returning veterans needing treatment for war-related trauma.

“These people have many problems and some of them very serious problems,” she said. “They have mental illness, complicated by addiction, complicated by post-traumatic stress disorder, and they’re left to be seen by the providers who have the least level of training and experience.”

Philip Hyde, a clinical psychologist in Oklahoma City and board member of the Mental Health Association of Central Oklahoma, said he thought the existing provider network could accommodate a reasonable influx of newly insured people.

He agreed that Oklahoma, like other states, has a shortage of psychiatrists. But he expressed confidence that the existing ranks of psychologists, licensed professional counselors and licensed clinical social workers could boost their patient load.

“If there were insurance, I think there would be enough professionals,” Hyde said. “The problem is so many people in Oklahoma are either not insured or underinsured. Unfortunately, even therapy goes where the money is.”

For people who obtain health plans through the government marketplace, the availability of mental health and substance abuse providers will depend on where they live and which company and policy they choose.

For example, Blue Cross Blue Shield lists a total of 82 psychiatric providers within a 10-mile radius of central Oklahoma City, 55 within a 10-mile radius of central Tulsa and none within a 10-mile radius of Stroud.

But even within the Blue Cross Blue Shield network, the number depends on the specific policy chosen. For lower-cost “Blue Preferred” policies, the roster shrinks to 67 in Oklahoma City and 19 in Tulsa. For even cheaper “Blue Advantage” polices, the company lists none in central Oklahoma City and two in Tulsa.

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